Northern Lincolnshire and Goole NHS Foundation Trust

10. Mrs M complains about the care her daughter, Ms Y, received from Northern Lincolnshire and Goole NHS Foundation Trust in July 2022. She complains it: • refused to give her daughter appropriate pain relief during the final days of her admission • inappropriately discharged her when she was not well enough • incorrectly prescribed her with codeine when it discharged her despite knowing she was on a methadone programme.

11. She says the Trust’s actions led to her daughter’s sad death and this could have been prevented if the Trust had taken different action and not discharged her. She told us this experience has massively impacted her own life. She says she now has anxiety, nervousness, she cannot sleep, she had been diagnosed with globus sensation (a feeling of a lump in the throat) due to stress, and she has had counselling to try and help her. She says her life will never be the same again and she cannot move forward with her life.

12. Mrs M wants an apology, an acknowledgement of failings, service improvements, and a financial remedy.

13. This very brief background is only intended to place the key events in context, not to provide a full, chronological account of everything that happened.

14. Ms Y was on a methadone programme at the time of events. Methadone is used to treat dependence on other drugs. The Trust admitted her at the beginning of July 2022 because she experienced ongoing back pain and it referred her to the pain Management team four days later. The Trust discharged Ms Y eight days after it admitted her. She sadly died the following day from drug toxicity (unsafe levels of drugs in the body).

Pain medication 17. Mrs M complains that when the Trust admitted her daughter because of back pain in July 2022, it did not give her appropriate pain relief to help her manage during the last three days of her admission. She told us she is concerned her daughter self-medicated because of this and says this could have been avoided had the Trust managed her pain. She explained that her daughter sadly died because she self-medicated.

18. We were sorry to hear how the Trust’s management of her daughter’s pain causes Mrs M distress. From what she told us, she has been through a significantly difficult time since her daughter’s sad death and her concerns about her daughter’s care continue to cause her ongoing upset.

19. The BNF says a weak opioid (a type of medication to relieve pain), either alone or with paracetamol, can be used to manage acute low back pain. It says paracetamol alone is ineffective for managing lower back pain.

20. Guidance from the NHS Greater Glasgow and Clyde gives advice on pain management in patients on long term methadone. As Mrs M’s daughter was on methadone, this guidance relates to her. The guidance says opioids should be used as needed, and the care of patients using methadone can be complex and their pain difficult to manage so clinicians should contact the pain team for further advice.

21. Our adviser explained that treatment for lower back pain usually consists of paracetamol four times a day and codeine as required (60mg up to four times a day). Codeine is an opioid. This information reflects the advice from the BNF above.

22. The Trust admitted Mrs M’s daughter at the beginning of July because of ongoing back pain. The medical records show the Trust gave Mrs M’s daughter ten doses of codeine during her eight-day admission. It also gave her two doses of oral paracetamol, and IV paracetamol during five days of her admission.

23. Our adviser explained that although the Trust did give Mrs M’s daughter codeine to help manage her pain, it did not give her the maximum dose (four doses per day) of codeine it could have done. We can see the Trust gave her paracetamol as pain relief, but the BNF advice says paracetamol alone is ineffective for managing low back pain.

24. From what we have seen in the medical records, Mrs M’s daughter’s electronic observation charts mark her pain score as zero or one (low) on the dates Mrs M complains about. However, the handwritten pain charts we have seen show that she was in moderate to severe pain before the Trust gave her doses of pain relief during three days of her admission, and she continued to report moderate pain following pain relief on these dates. We can also see her daughter appeared to be in pain and requested additional pain relief on the days Mrs M complains about.

25. The information recorded in the medical records about the amount of pain she experienced is conflicting and this means it is not clear what happened or if the Trust responded to her reports of pain.

26. The Trust discharged Mrs M’s daughter eight days after it admitted her as it felt it had controlled the symptoms she presented with on admission and arranged for her to be seen by the pain team in the community.

27. Our adviser explained that based on the handwritten pain charts and the medication charts, the Trust did not optimally manage Mrs M’s daughter’s pain. This is because she had continued pain, and it was not improving after taking the prescribed pain medication. They explained that as the Trust had tried paracetamol and codeine and Mrs M’s daughter continued to experience pain, it could have tried a stronger opioid medication such as morphine and oxycodone to manage her pain. We have not seen any evidence to suggest it considered doing this.

28. It is difficult for us to reach a conclusion about what happened with the Trust’s management of Mrs M’s daughter’s pain. This is because the information recorded in the medical records about how much pain she experienced during her admission is conflicting.

29. However, we have seen indications in the medical records that her daughter was still in pain following the pain medication and she also requested additional pain relief. We have also considered our adviser’s view that the Trust did not give Mrs M’s daughter the maximum amount of codeine medication it could have done to help manage her pain.

30. After considering this information and on the balance of probabilities, we think the Trust did not manage Mrs M’s daughter’s pain as well as it could have done and therefore it did not consistently follow BNF guidance on treating lower back pain.

31. Although the Trust did refer Mrs M’s daughter to be reviewed by the pain team following her discharge, we have not seen any evidence to suggest it considered further opioids in line with guidance from NHS Greater Glasgow and Clyde. We think the Trust inconsistently followed this guidance and this is a failing.

32. As we have seen that something went wrong when the Trust managed Mrs M’s daughter’s pain relief, we have gone on to consider the impact of this on both Mrs M and her daughter.

33. Mrs M told us her daughter self-medicated because the Trust did not effectively manage her pain. She said this led to her sad death following her discharge. We were sorry to hear Mrs M’s concerns that the Trust could have prevented her daughter’s sad death with different action and how this has impacted her own mental and physical health because of the distress this causes her.

34. Our adviser explained that it is difficult to say how the Trust’s actions impacted Mrs M’s daughter. However, it is likely that she would have experienced some level of pain, and we can see this is supported by the handwritten pain charts in the medical records and her daughter’s request for more pain medication on two occasions.

35. Unfortunately, we cannot say how much pain Mrs M’s daughter experienced because of the conflicting medical records or speculate whether this led her to self-medicate as Mrs M believes.

36. This means we do not think the Trust’s management of Mrs M’s daughter’s pain, led to her sad death. We can see the Trust did give her some pain relief and referred her to the pain management team, so it partially managed her pain in line with guidance from NHS Greater Glasgow and Clyde and the BNF.

37. Our Principles of Remedy say that to put things right, organisations should provide an apology, explanation, and an acknowledgement of responsibility.

38. In its responses to the complaint, the Trust explained what pain medication it gave to Mrs M’s daughter and when. It apologised for the distress and concern she experienced due to her daughter’s care, which is in line with our Principles.

39. However, it does not acknowledge it missed an opportunity to fully optimise Mrs M’s daughter’s pain during her admission or the distress this had on Mrs M. We cannot see any evidence to suggest it has considered any service improvements to stop the same thing from happening again.

40. Based on the evidence we have considered, we partly uphold this complaint and make recommendations as the Trust has not fully remedied and recognised the distress or uncertainty its actions caused Mrs M.

41. From what Mrs M told us, it is clear that her concerns about how the Trust managed her daughter’s pain relief during her admission continue to cause her ongoing worry. We hope that our findings regarding this, gives her some reassurance that the Trust’s actions do not appear to have impacted her daughter’s sad outcome, and clarifies any information she was unsure about.

Discharge 42. Mrs M also complains about her daughter’s discharge. She is concerned the Trust gave her daughter a prescription for codeine when it discharged her and says this was unsafe as her daughter was on a methadone programme. We were sorry to hear how Mrs M’s concerns about the Trust’s choice of medication for her daughter continues to worry her.

43. As we explain above, the guidance from NHS Greater Glasgow and Clyde gives advice on pain management for patients on long term methadone and relates to Mrs M’s daughter.

44. Mrs M’s daughter’s discharge summary shows the Trust discharged her daughter with a prescription for codeine eight days after it admitted her. It also referred her to the pain management service in the community for further review.

45. Based on the guidance from NHS Greater Glasglow and Clyde, we cannot say the Trust’s decision to discharge Mrs M’s daughter with codeine was wrong as it appears it followed this guidance which says opioids (such as codeine) can be used as needed.

46. Therefore, we are satisfied that the Trust’s actions here are in line with NHS Greater Glasglow and Clyde guidance. As we found above, it also referred Mrs M’s daughter to the pain team in the community for further management which the guidance says it must. This means we have seen no indications that the Trust got anything wrong. We hope our findings here help to provide Mrs M with some reassurance that the Trust followed relevant guidance when it discharged her daughter with a prescription for codeine.

47. Mrs M is also understandably concerned the Trust discharged her daughter when she was not medically fit enough to go home. She says her daughter did not want to be discharged and it is unclear if a doctor reviewed her to make this decision. She told us her daughter sadly died a few hours after her discharge from a slow build-up of medication in her body which led to heart failure. She says this could have been prevented if the Trust had taken different action.

48. We were sorry to hear Mrs M’s concerns about how the Trust managed her daughter’s discharge. This was clearly a distressing time for Mrs M as her daughter sadly died shortly after her discharge, and it is understandable that her concerns about the Trust’s actions continue to cause her significant worry.

49. NHSE’s criteria to reside guidance explains the factors that clinicians should consider when they plan to discharge adult patients from hospital. For example, staff should consider if the patient needs intensive or high dependency care, oxygen, intravenous fluids, are in their last hours of life, or their NEWS2 score is greater than three before deciding to discharge them.

50. A NEWS2 score assesses the clinical status of patients and detects early warning signs of deterioration. A low score such as zero, indicates a patient is at low risk of deteriorating. If the answer is no to each of the listed criteria, the patient can be discharged to a less acute setting such as their home.

51. NMC the Code says nurses should make a timely referral to another practitioner when any action, care, or treatment is required. GMC guidance says clinicians must promptly provide or arrange suitable advice, investigations, or treatment where necessary.

52. The Trust reviewed Mrs M’s daughter on the morning of her discharge. The doctor noted that she was not in pain, she was mobile, and able to move all four limbs. They documented that she was due to be seen by the pain team in the community following her discharge. Her NEWS score was zero during this review and the Trust discharged her at 6pm.

53. Our adviser explained that based on the criteria to reside guidance from NHSE, Mrs M’s daughter was medically fit to be discharged as she did not meet the criteria to stay in hospital or appear to need further inpatient management for her symptoms. For example, her NEWS2 score was zero and she did not appear to need intravenous fluids or oxygen. We can also see she was reviewed by a doctor on the morning of her discharge. We hope this clarifies the information Mrs M was unsure about.

54. However, although it appears Mrs M’s daughter was medically fit enough for the Trust to discharge her based on the NHSE criteria to reside guidance, we have seen indications in the medical records that something may have gone wrong with her care before her discharge.

55. Two days before her discharge, the Trust documented that Mrs M’s daughter was very drowsy after spending time outside and she was not on the ward for her evening medications. The medical records document Mrs M’s daughter had been missing from the ward for several hours that evening.

56. When Mrs M’s daughter returned to the ward, the nursing staff documented that she appeared very drowsy, had glassed eyes, and noted the possibility she may have taken something (such as medication).

57. In the early hours on the day of her discharge, the medical records document Mrs M’s daughter left the ward. When she returned at around 4am, the nursing staff documented that she appeared spaced out and another patient told the nursing staff that Mrs M’s daughter had taken 15 pregabalin (used for pain relief) and 14 nitrozen (our adviser explained this is likely to be a misspelling and could be nitrazepam which is a sedative). The nursing staff queried if this was true as Mrs M’s daughter was alert and awake but continued to slur her words.

58. Later that day in the afternoon, Mrs M’s daughter raised concerns to the Trust about returning to her current home. The nursing staff asked her if she wanted them to make a safeguarding referral and she accepted this offer. From the information we have seen in the medical records, Mrs M’s daughter was not happy to be discharged home.

59. Our adviser explained that the amount of medication Mrs M’s daughter is reported to have taken in the early hours of the morning is excessive. We have not seen any evidence to suggest the Trust addressed this incident or acted upon it. Our adviser explained that if the Trust had acted on the documentation in the medical records that Mrs M’s daughter had taken an excessive amount of medication, it is likely it would have referred to Toxbase.

60. Toxbase is the primary clinical toxicology data base of the National Poisons Information Service. It gives information about the management of patients exposed to drugs and advises clinicians how to diagnose, treat, manage, and monitor patients who have been poisoned, whether from an excessive amount of medication or otherwise. The BNF’s treatment summary on poisoning says Toxbase should be consulted when there is a doubt about the degree of risk or about management.

61. NMC guidance says nurses should make a timely referral to another practitioner when any action is required. We cannot see any evidence in the medical records to show the nursing staff escalated their concerns to the medical team that that Mrs M’s daughter may have taken additional medication two days before her discharge or on the morning of her discharge. We also cannot see any evidence to show the Trust acted on Mrs M’s daughter’s request for a safeguarding referral before it discharged her, in line with the same guidance. This is a failing.

62. This failing is further compounded by the fact we do not think the medical team reviewed the information recorded in the medical records when it assessed Mrs M’s daughter during the ward round on the morning it discharged her. We consider the team missed an opportunity to address the fact she had possibly taken an excessive amount of medication earlier that morning. This action falls short of GMC guidance which says clinicians must promptly provide or arrange suitable advice, investigations, or treatment where necessary.

63. As we have seen that something went wrong with Mrs M’s daughter’s care, we have gone on to consider the impact of this on them both.

64. Mrs M told us that her daughter sadly died a few hours after the Trust discharged her. She told us the Trust failed to act when another patient told it her daughter had taken an excessive amount of medication. She says it could have prevented her sad death if it had taken different action and kept her in hospital.

65. Mrs M explained her life will never be the same again following the sad death of her daughter. She told us the experience has massively impacted her, and she has anxiety and cannot sleep. She has had counselling to try and help her. From our conversations with Mrs M, it is clear this experience has been significantly distressing and painful for her. It is understandable that her concerns about the Trust’s actions when it managed her daughter’s care continue to impact her and cause her the distress she told us about.

66. Our adviser explained that it is difficult for us to know what management Toxbase would have recommended to the Trust about how long to observe Mrs M’s daughter for following her reports that she had taken an excessive amount of medication on the day of her discharge.

67. Toxbase would have considered the medication Mrs M’s daughter is believed to have taken in excess as well as the prescription medication she was already taking. It is possible that it may have recommended a longer period of observation which could have impacted the time the Trust discharged Mrs M’s daughter, or the period of observation may well have ended by the time she was discharged that evening. However, we cannot be certain about this or what impact this could have had on her.

68. As Mrs M explained, her daughter sadly died from drug toxicity the morning after the Trust discharged her. Drug toxicity means she had unsafe levels of drugs in her body. The coroner carried out an inquest into her sad death, and it appears she had further, additional medications in her blood that the Trust had not prescribed. Our adviser explained this is likely to have impacted her deterioration and sad death. This means it is unlikely that we can link her daughter’s sad death to the Trust’s actions because we cannot say what her drug toxicity levels were before the Trust discharged her.

69. Unfortunately, we also cannot say what would have happened had the Trust completed a safeguarding referral for Mrs M’s daughter after she requested one on the day of her discharge. We do not know if the safeguarding team would have reviewed her daughter following the referral, when this review may have taken place, or if the Trust would have continued with Mrs M’s daughter’s discharge.

70. Therefore, we cannot say with any certainty if either of these failings would have changed the Trust’s plans to discharge Mrs M’s daughter at the time it did. This means we cannot link what went wrong to the full impact claimed by Mrs M, that her daughter’s sad death could have been prevented, for this reason. We recognise this may disappointing for Mrs M and we are sorry we cannot provide a further explanation or clarity about this.

71. We do recognise however that Mrs M will never know if different action from the Trust could have impacted her daughter’s discharge and how this uncertainty continues to cause her significant distress.

72. Our Principles of Remedy say that to put things right, organisations should provide an apology, explanation, and an acknowledgement of responsibility.

73. In the Trust’s response to the complaint, it explained that it planned Mrs M’s daughter’s discharge because it had medically optimised her clinical condition. It explained it considered her daughter was medically fit for discharge at the point of her leaving the Trust. It attempted to reassure Mrs M by explaining that her daughter’s NEWS score was zero before it discharged her and therefore at low risk of deteriorating.

74. The Trust carried out an investigation into Mrs M’s concerns in July 2023, and it acknowledged what should have happened when nursing staff were made aware her daughter may have taken an excessive amount of medication. It says it staff have escalated this concern so the Trust could have monitored and observed her daughter. We have not seen any evidence to suggest that the Trust has acknowledged this to Mrs M specifically or apologised to her for this. We also cannot see it has put any service improvements in place to stop the same thing from happening again, despite this acknowledgement.

75. In the Concise Investigation Report, the Trust also acknowledged that the staff should have contacted its Safeguarding Adults Team for advice and support on a possible safeguarding referral for Mrs M’s daughter. It explained there was a breakdown in communication between staff, and this is why this did not happen.

76. As a result of the investigation, the Trust implemented service improvements and organised a focused staff training session for safeguarding and the processes that should be followed. Again, we have not seen that the Trust has acknowledged what went wrong to Mrs M or apologised for it.

77. Based on this, we cannot see it has fully acknowledged what went wrong, remedied the distress this caused Mrs M, or fully considered what it can do to prevent the same thing from happening again. Therefore, we partly uphold this complaint and make recommendations.

Conclusion 78. Based on what we have seen, the Trust did not get anything wrong when it discharged Mrs M’s daughter with a codeine prescription. It followed relevant guidelines from the BNF and NHS Greater Glasgow and Clyde when it made the decision to treat her daughter with codeine and discharge her with it.

79. We consider the Trust missed an opportunity to fully manage Mrs M’s daughter’s pain relief during her admission when it did not give her the maximum dosage of codeine or consider using another opiate in line with guidance from the BNF. It also missed an opportunity to escalate reports that Mrs M’s daughter took an excessive amount of medication, in line with both NMC and GMC guidance. We consider it missed the opportunity to escalate the need for a safeguarding referral in line with NMC guidance.

80. Although we have identified these failings in care, we cannot link them to the full impact Mrs M claims, that failings in her daughter’s care led to her sad death. This is because we do not know what would have happened if the Trust had managed her daughter’s pain in a different way or escalated her excessive medication intake and safeguarding concerns.

81. It is clear that this experience has caused Mrs M significant distress and worry. From our conversations with her, it is clear her daughter’s sad death has been a traumatic event for her. We consider the uncertainty of what happened during her daughter’s admission has added to her distress. We cannot see any evidence the Trust has fully acknowledged what happened, fully reflected on it, or remedied the impact the failings had on Mrs M.

82. Therefore, we partly uphold this complaint and make recommendations, as we can see that something went wrong that has not been fully remedied by the Trust.

1. Mrs M is understandably concerned that Northern Lincolnshire and Goole NHS Foundation Trust (the Trust) did not give her daughter enough pain relief during her admission in July 2022. She told us this meant her daughter self-medicated which led to her sad death.

2. We were sorry to hear Mrs M’s concerns about the care her daughter received from the Trust before her sad death, and the distress this caused her. From our conversations with Mrs M, it is clear this has been a significantly difficult time for her.

3. We consider the Trust did not consistently follow relevant guidelines when it managed Mrs M’s daughter’s pain relief and it missed opportunities to fully optimise this. Although this does not appear to have impacted her daughter’s sad death, we do consider it led to some of the distress Mrs M told us about. We do not consider the Trust has recognised or acknowledged what went wrong or explained what steps it has taken to try and prevent the same thing from happening again.

4. Mrs M also complains the Trust discharged her daughter with a prescription for codeine and when she was not medically fit enough to go home. We were sorry to hear Mrs M’s concerns about how the Trust managed her daughter’s discharge.

5. From what she told us, Mrs M is concerned these actions led to her daughter’s sad death a few hours after her discharge. It is clear from our conversations that Mrs M believes different action from the Trust could have improved her daughter’s sad outcome and we are sorry her concerns continue to cause her ongoing distress.

6. We consider the Trust followed relevant guidelines when it discharged Mrs M’s daughter with codeine and we have decided to take no further action on this part of the complaint for this reason.

7. However, the Trust did not follow relevant guidelines when it missed the opportunity to escalate a safeguarding request or reports that Mrs M’s daughter had taken an excessive amount of medication before her discharge. We do not consider this led to Mrs M’s daughter’s sad death, but we do think this is likely to have contributed to the uncertainty and distress Mrs M told us she experienced.

8. Although the Trust has acknowledged something went wrong here and made improvements to its service relating to safeguarding, it has not considered how it could improve its service when patients share concerns about taking excessive medication, as in Mrs M’s daughter’s case. We do not consider it has fully recognised what happened, how this impacted Mrs M, or explained what steps it has taken to try and prevent the same thing from happening again.

9. We partly uphold these complaints and make recommendations at the end of our report. This is because we have found failings in some of the complaint that led to some of the impact Mrs M described. From what she told us, it is understandable that her experience has been distressing and worrying for her. We hope our report helps to answer her concerns and clarifies any information she is unsure about.